New York State Department of Health
2016 Nursing Home Quality Initiative Methodology
Updated March 2016
The 2016 Nursing Home Quality Initiative (NHQI) is comprised of three components: [1] the Quality
Component (quality measures), [2] the Compliance Component (compliance with reporting), [3] and the
Efficiency Component (potentially avoidable hospitalizations). The 2016 NHQI score is worth a
maximum 100 points.
Quality Component (70 points)
Quality measures are calculated from MDS 3.0 data (2015 calendar year), the NYS employee flu
vaccination data, and nursing home cost report data for the percent of contract/agency staff used and
the rate of staffing hours per day.
Year 2
Performance
 The allotted 70 points for quality are distributed evenly for all quality measures. The 2016 NHQI
includes 14 quality measures with each measure being worth a maximum of 5 points.
 Four quarters of 2015 MDS 3.0 data are used.
 The quintiles are based on the same measurement year of the results. Therefore only a certain
number of nursing homes are able to achieve these quintiles for each measure. The results are
not rounded until after determining the quintile for measures. For measures with very narrow
ranges of performance, two facilities may be placed in different quintiles and receive different
points, but after rounding, the facilities may have the same rate.
 For quality measures that are awarded points based on their quintile distribution, nursing
homes will be rewarded for achieving high performance as well as improvement from previous
years’ performance. Note that improvement points will not apply to quality measures that are
based on threshold values. See the Quality Point Grid for Attainment and Improvement below.
Assuming each quality measure is worth 5 points, the distribution of points based on two years
of performance is demonstrated in the grid.
Quality Point grid for Attainment and Improvement
Year 1 Performance
Quintiles
1
2
3
4
5
1 (best)
5
5
5
5
5
2
3
3
4
4
4
3
1
1
1
2
2
4
0
0
0
0
1
5
0
0
0
0
0
Year 1 = 2015 (2014 measurement year)
Year 2 = 2016 (2015 measurement year)
For example, if 2015 NHQI performance (Year 1) is in the third quintile, and 2016 NHQI
performance (Year 2) is in the second quintile, the facility will receive 4 points for the measure.
This is 3 points for attaining the second quintile and 1 point for improvement from the previous
year’s third quintile.
Changes to the Quality Component
 Rate of staffing hours per day
o The CMS Five-Star Quality Rating for Staffing has been replaced with the Rate of Staffing
Hours per Day. This is a NYS DOH measure that calculates a case-mix adjusted rate of
staffing hours per day using nursing home cost report and MDS data. The hours
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reported are taken from the hours worked field for RNs, LPNs, and Aides on the nursing
home cost report. The hours expected are computed using the MDS RUG distribution of
the nursing home residents and the CMS Time Staff Measurement Studies. The hours
reported are divided by the hours expected and multiplied by the statewide average to
create a case-mix-adjusted staffing rate. Like the previous CMS Five-Star Quality Rating
for Staffing, this measure will be awarded points based on the quintile method.
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Quality Measures (70 points)
The 14 quality measures for the 2016 NHQI are shown in the table below.
Number
1
Measure
Percent of contract/agency staff
used
2
Rate of Staffing Hours per Day
3
Percent of employees vaccinated
for influenza
Measure
Steward
Data Source and
Measurement Period
NYS DOH
Nursing home cost report,
2015 calendar year for
calendar filers and 2015 fiscal
year for fiscal filers
NYS DOH
NYS DOH
Nursing home cost report,
2015 calendar year for
calendar filers and 2015 fiscal
year for fiscal filers, and MDS
3.0, 2015 calendar year
Employee vaccination data
submitted to the Bureau of
Immunization through HERDS
for the 2015-2016 influenza
season
Scoring Method
Notes
Eligible for
Improvement
in 2016 NHQI
Threshold
Maximum points are
awarded if the rate is less
than 10%, and zero points
if the rate is 10% or
greater.
No
Quintile
Replaces CMS Five-Star
Quality Rating for Staffing
No
Threshold
Maximum points are
awarded if the rate is 85%
or greater, and zero points
if the rate is less than 85%
No
Risk adjusted by the NYS
DOH
Yes
MDS 3.0 Quality Measures
4
Percent of long stay high risk
residents with pressure ulcers
CMS
MDS 3.0, 2015 calendar year
Quintile
5
Percent of long stay residents who
received the pneumococcal
vaccine*
CMS
MDS 3.0, 2015 calendar year
Quintile
Yes
6
Percent of long stay residents who
received the seasonal influenza
vaccine*
CMS
MDS 3.0, 2015 calendar year
Quintile
Yes
CMS
MDS 3.0, 2015 calendar year
Quintile
Yes
Percent of long stay residents
experiencing one or more falls with
major injury
*a higher rate is better
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Eligible for
Improvement
in 2015 NHQI
Number
Measure
Measure
Steward
Data Source and
Measurement Period
Scoring Method
8
Percent of long stay residents who
have depressive symptoms
CMS
MDS 3.0, 2015 calendar
year
Quintile
Yes
9
Percent of long stay low risk residents
who lose control of their bowel or
bladder
CMS
MDS 3.0, 2015 calendar
year
Quintile
Yes
10
Percent of long stay residents who
lose too much weight
CMS
MDS 3.0, 2015 calendar
year
Quintile
11
Antipsychotic use in persons with
dementia
PQA
MDS 3.0, 2015 calendar
year
Quintile
12
Percent of long stay residents who
self-report moderate to severe pain
CMS
MDS 3.0, 2015 calendar
year
Quintile
13
Percent of long stay residents whose
need for help with daily activities has
increased
CMS
MDS 3.0, 2015 calendar
year
Quintile
Yes
14
Percent of long stay residents with a
urinary tract infection
CMS
MDS 3.0, 2015 calendar
year
Quintile
Yes
Notes
Risk adjusted by the NYS
DOH
Yes
Yes
Risk adjusted by the NYS
DOH
Yes
*a higher rate is better
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Compliance Component (20 points)
The compliance component consists of three areas: CMS’ five-star quality rating for health inspections,
timely submission of nursing home certified cost reports, and timely submission of employee influenza
immunization data.
 CMS Five-Star Quality Rating for Health Inspections (regionally adjusted)
o CMS’ facility ratings for the health inspections domain are based on the number, scope,
and severity of the deficiencies identified during the three most recent annual
inspection surveys, as well as substantiated findings from the most recent 36 months of
complaint investigations. All deficiency findings are weighted by scope and severity. The
CMS rating also takes into account the number of revisits required to ensure that
deficiencies identified during the health inspection survey have been corrected.
o The health inspection survey scores from CMS will be used to calculate cut points for
each region in the state. Regions include the Metropolitan Area, Western New York,
Capital District, and Central New York. Per CMS’ methodology, the top 10% of nursing
homes will receive five stars, the middle 70% will receive four, three, or two stars, and
the bottom 20% will receive one star. Each nursing home will be awarded a Five-Star
Quality Rating based on the cut points calculated from the health inspection survey
scores within its region. Ten points are awarded for obtaining five stars or the top 10
percent (lowest 10 percent in terms of health inspection deficiency score). Seven points
for obtaining four stars, four points for obtaining three stars, two points for obtaining
two stars, and zero points for one star.
 Timely submission measures
o Submission of employee influenza vaccination data to the NYS DOH Bureau of
Immunization for the 2015-2016 influenza season by the deadline of May 1, 2016 is
worth five points.
o Submission of certified and complete 2015 nursing home cost reports to the NYS DOH
by the deadlines of July 15, 2016 for calendar year filers, and October 31, 2016 for fiscal
year filers, is worth five points.
The three compliance measures for the 2016 NHQI are shown in the table below.
Number
Measure
1
CMS Five-Star Quality Rating
for Health Inspections
(regionally adjusted)
Measure
Steward
CMS
Data Source and
Measurement Period
Scoring Method
CMS health inspection survey
scores as of April 1, 2016
5 stars=10 points
4 stars=7 points
3 stars=4 points
2 stars=2 points
1 star=0 points
Five points for
submission by the
deadline
Five points for
timely, certified and
complete
submission of the
2015 cost report
2
Timely submission of employee
NYS DOH
influenza vaccination data
Employee influenza
vaccination data submitted to
the Bureau of Immunization
through HERDS for the 20152016 influenza season
3
Timely submission of certified
and complete nursing home
cost reports
Nursing home cost report,
2015 calendar year for
calendar filers and 2015 fiscal
year for fiscal filers
NYS DOH
5
Efficiency Component (10 points)
 To align with the other CMS quality measures, the Potentially Avoidable Hospitalizations
rate will be calculated for each quarter, then averaged to create an annual average.
 The PAH measure is risk adjusted.
Number
Measure
Steward
Measure
Potentially Avoidable
Hospitalizations
1
CMS/NYS
DOH
Data Source and
Measurement Period
Scoring Method
MDS 3.0 and SPARCS, 2015
calendar year
Quintile 1=10 points
Quintile 2=8 points
Quintile 3=6 points
Quintile 4=2 points
Quintile 5=0 points
Scoring
The facility’s overall score will be calculated by summing the points for each measure in the NHQI. In the
event that a measure cannot be used due to small sample size or unavailable data, the maximum
attainable points will be reduced for that facility. For example, if a facility has a small sample size on two
of its quality measures (each 5 points), the maximum attainable points will be 90 rather than 100. The
sum of its points will be divided by 90 to calculate its total score. The example below provides a
mathematical illustration of this method.
Facility A
Facility B
no small sample size
small sample size on
two quality measures
Sum of points
Maximum points
attainable
Score ratio
(points/maximum)
80
80
100
90
.80
.89
Final score x 100
80
89
Ineligibility for NHQI Ranking
Due to the severity of letter J, K, and L health inspection deficiencies, receipt of a deficiency is
incorporated into the NHQI. Nursing homes that receive one or more of these deficiencies are not
eligible to be ranked into overall quintiles. J, K, and L deficiencies indicate a Level 4 immediate jeopardy,
which is the highest level of severity for deficiencies on a health inspection. Immediate jeopardy
indicates that the deficiency resulted in noncompliance and immediate action was necessary, and the
event caused or was likely to cause serious injury, harm, impairment or death to the resident(s).
 Deficiency data shows a J/K/L deficiency between July 1 of the measurement year (2015)
and June 30 of the reporting year (2016).
 Deficiencies will be assessed on October 1 of the reporting year to allow a three-month
window for potential Informal Dispute Resolutions (IDR) to process.
 Any new J/K/L deficiencies between July 1 and September 30 of the reporting year (2016)
will not be included in the current NHQI; they will be included in the next NHQI cycle.
Nursing Home Exclusions from NHQI
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The following types of facilities will be excluded from the NHQI and will not contribute to the pool or be
eligible for payment:
 Non-Medicaid facilities
 Any facility designated by CMS as a Special Focus Facility at any time during 2015 or 2016,
prior to the final calculation of the 2016 NHQI
 Specialty facilities
 Specialty units within a nursing home (i.e. AIDS, pediatric specialty, traumatic brain injury,
ventilator dependent, behavioral intervention)
 Continuing Care Retirement Communities
 Transitional Care Units
Schedule for the 2016 NHQI




May 1, 2016 – Employee influenza vaccination data due
July 15, 2016 – Nursing home certified and complete cost reports due for calendar year filers
October 31, 2016 - Nursing home certified and complete cost reports due for fiscal year filers
December 2016 – NYS DOH will release preliminary results on the Health Commerce System for
feedback
 January 2017 – NYS DOH will release the final results of the 2016 NHQI on the Health Commerce
System and on Health Data NY
 Early 2017 – NYS DOH will release the methodology for the 2017 NHQI
For more information about the NHQI methodology, please contact the Office of Quality and Patient
Safety at [email protected].
Measure specifications for the CMS Quality Measures used in the 2016 NHQI can be found in the MDS
3.0 Quality Measures User’s Manual, Version 8.0, at https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User%E2%80%99sManual-V80.pdf.
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